Pain

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This article is about physical pain. For pain in the broader sense, see Suffering. For other uses, see Pain (disambiguation).

Pain

ICD-10 ICD-9 DiseasesDB MedlinePlus MeSH

R52 338 9503 002164 D010146

Pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."[1] It is the feeling common to such experiences as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone".[2] Pain motivates us to withdraw from potentially damaging situations, protect a damaged body part while it heals, and avoid those situations in the future.[3] Most pain resolves promptly once the painful stimulus is removed and the body has healed, but sometimes pain persists despite removal of the stimulus and apparent healing of the body; and sometimes pain arises in the absence of any detectable stimulus, damage or disease.[4] Pain is the most common reason for physician consultation in the United States.[5] It is a major symptom in many medical conditions, and can significantly interfere with a person's quality of life and general functioning.[6] Psychological factors such as

social support, hypnotic suggestion, excitement in sport or war and distraction can significantly modulate pain's intensity or unpleasantness.[7][8]

Contents
[hide]

1 Classification o 1.1 Duration o 1.2 Region and system o 1.3 Cause o 1.4 Nociceptive o 1.5 Neuropathic o 1.6 Phantom o 1.7 Psychogenic o 1.8 Pain asymbolia and insensitivity 2 Effect on functioning 3 Theory o 3.1 Specificity o 3.2 Pattern o 3.3 Gate control o 3.4 Dimensions o 3.5 Theory today o 3.6 Evolutionary and behavioral role o 3.7 Thresholds 4 Assessment o 4.1 Multidimensional pain inventory o 4.2 In nonverbal patients o 4.3 Other barriers to reporting o 4.4 As an aid to diagnosis 5 Management o 5.1 Medication o 5.2 Psychological o 5.3 Alternative medicine 6 Epidemiology 7 Society and culture 8 In other animals 9 Etymology 10 References 11 External links

[edit] Classification
The International Association for the Study of Pain (IASP) classification system describes pain according to five categories: duration and severity, anatomical location, body system involved, cause, and temporal characteristics (intermittent,

constant, etc.).[4] This system has been criticized by Woolf and others as inadequate for guiding research and treatment,[9] and an additional category based on neurochemical mechanism has been proposed.[10]

[edit] Duration
Main article: Chronic pain
Pain is usually transitory, lasting only until the noxious stimulus is removed or the underlying damage or pathology has healed, but some painful conditions, such as rheumatoid arthritis, peripheral neuropathy, cancer and idiopathic pain, may persist for years. Pain that lasts a long time is called chronic, and pain that resolves quickly is called acute. Traditionally, the distinction between acute and chronic pain has relied upon an arbitrary interval of time from onset; the two most commonly used markers being 3 months and 6 months since the onset of pain,[10] though some theorists and researchers have placed the transition from acute to chronic pain at 12 months.[11] Others apply acute to pain that lasts less than 30 days, chronic to pain of more than six months duration, and subacute to pain that lasts from one to six months.[12] A popular alternative definition of chronic pain, involving no arbitrarily fixed durations is "pain that extends beyond the expected period of healing."[10] Chronic pain may be classified as "malignant" (caused by cancer) or "benign" (nonmalignant).[12]

[edit] Region and system

Pain can be classed according to its location in the body, as in headache, low back pain and pelvic pain; or according to the body system involved, such as myofascial pain (emanating from skeletal muscles or the fibrous sheath surrounding them), rheumatic pain (emanating from the joints and surrounding tissue), neuropathic pain (caused by damage or illness affecting the somatosensory system), or vascular (pain from blood vessels).[10]

[edit] Cause
The crudest example of classification by cause simply distinguishes "somatogenic" pain (arising from a perturbation of the body) from psychogenic pain (arising from a perturbation of the mind: when a thorough physical exam, imaging, and laboratory tests fail to detect the cause of pain, it is assumed to be the product of psychic conflict or psychopathology).[10] Somatogenic pain is divided into "nociceptive" and "neuropathic".[13]

[edit] Nociceptive
Nociceptive pain is caused by stimulation of peripheral nerve fibers that respond only to stimuli approaching or exceeding harmful intensity (nociceptors), and may be classified according to the mode of noxious stimulation; the most common

categories being "thermal" (heat or cold), "mechanical" (crushing, tearing, etc.) and "chemical" (iodine in a cut, chili powder in the eyes). Nociceptive pain may also be divided into "visceral," "deep somatic" and "superficial somatic" pain. Visceral pain originates in the viscera (organs) and often is extremely difficult to locate, and nociception from some visceral regions may produce "referred" pain, where the sensation is located in an area distant from the site of the stimulus. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorlylocalized pain. Examples include sprains and broken bones. Superficial pain is initiated by activation of nociceptors in the skin or other superficial tissue, and is sharp, well-defined and clearly located. Examples of injuries that produce superficial somatic pain include minor wounds and minor (first degree) burns.[11]

[edit] Neuropathic
Main article: Neuropathic pain
Neuropathic pain is caused by damage or disease affecting the central or peripheral portions of the nervous system involved in bodily feelings (the somatosensory system).[14] Peripheral neuropathic pain is often described as burning, tingling, electrical, stabbing, or pins and needles.[15] Bumping the "funny bone" elicits peripheral neuropathic pain.

[edit] Phantom
Main article: Phantom pain
Phantom pain is pain from a part of the body that has been lost or from which the brain no longer receives signals. It is a type of neuropathic pain. Phantom limb pain is a common experience of amputees. The prevalence of phantom pain in upper limb amputees is nearly 82%, and in lower limb amputees is 54%.[16] One study found that eight days after amputation, 72 percent of patients had phantom limb pain, and six months later, 65 percent reported it.[17][18] Some amputees experience continuous pain that varies in intensity or quality; others experience several bouts a day, or it may occur only once every week or two. It is often described as shooting, crushing, burning or cramping. If the pain is continuous for a long period, parts of the intact body may become sensitized, so that touching them evokes pain in the phantom limb, or phantom limb pain may accompany urination or defecation.[19] Local anesthetic injections into the nerves or sensitive areas of the stump may relieve pain for days, weeks or, sometimes permanently, despite the drug wearing off in a matter of hours; and small injections of hypertonic saline into the soft tissue between vertebrae produces local pain that radiates into the phantom limb for ten minutes or so and may be followed by hours, weeks or even longer of partial or total relief from phantom pain. Vigorous vibration or electrical stimulation of the stump, or

current from electrodes surgically implanted onto the spinal cord all produce relief in some patients.[19] Work by Vilayanur S. Ramachandran using mirror box therapy allows for illusions of movement and touch in a phantom limb which in turn cause a reduction in pain.[20] Paraplegia, the loss of sensation and voluntary motor control after serious spinal cord damage, may be accompanied by girdle pain at the level of the spinal cord damage, visceral pain evoked by a filling bladder or bowel, or, in five to ten per cent of paraplegics, phantom body pain in areas of complete sensory loss. This phantom body pain is initially described as burning or tingling but may evolve into severe crushing or pinching pain, fire running down the legs, or a knife twisting in the flesh. Onset may be immediate or may not occur until years after the disabling injury. Surgical treatment rarely provides lasting relief.[19]

[edit] Psychogenic
Main article: Psychogenic pain
Psychogenic pain, also called psychalgia or somatoform pain, is pain caused, increased, or prolonged by mental, emotional, or behavioral factors.[21] Headache, back pain, and stomach pain are sometimes diagnosed as psychogenic.[22] Sufferers are often stigmatized, because both medical professionals and the general public tend to think that pain from a psychological source is not "real". However, specialists consider that it is no less actual or hurtful than pain from any other source.[23] People with long term pain frequently display psychological disturbance, with elevated scores on the Minnesota Multiphasic Personality Inventory scales of hysteria, depression and hypochondriasis (the "neurotic triad"). Some investigators have argued that it is this neuroticism that causes acute injuries to turn chronic, but clinical evidence points the other way, to chronic pain causing neuroticism. When long term pain is relieved by therapeutic intervention, scores on the neurotic triad and anxiety fall, often to normal levels. Self-esteem, often low in chronic pain patients, also shows improvement once pain has resolved.[24] The term 'psychogenic' assumes that medical diagnosis is so perfect that all organic causes of pain can be detected; regrettably, we are far from such infallibility... All too often, the diagnosis of neurosis as the cause of pain hides our ignorance of many aspects of pain medicine. Ronald Melzack, 1996.[24]

[edit] Pain asymbolia and insensitivity

Main articles: Pain asymbolia and Congenital insensitivity to pain
The ability to experience pain is essential for protection from injury, and recognition of the presence of injury. Episodic analgesia may occur under special circumstances,

such as in the excitement of sport or war: a soldier on the battlefield may feel no pain for many hours from a traumatic amputation or other severe injury.[25] Although unpleasantness is an essential part of the IASP definition of pain, it is possible to induce a state described as intense pain devoid of unpleasantness in some patients, with morphine injection or psychosurgery.[23] Such patients report that they have pain but are not bothered by it, they recognize the sensation of pain but suffer little, or not at all.[26] Indifference to pain can also rarely be present from birth; these people have normal nerves on medical investigations, and find pain unpleasant, but do not avoid repetition of the pain stimulus.[27] Insensitivity to pain may also result from abnormalities in the nervous system. This is usually the result of acquired damage to the nerves, such as spinal cord injury, diabetes mellitus (diabetic neuropathy), or leprosy in countries where this is prevalent.[28] These individuals are at risk of tissue damage due to undiscovered injury. People with diabetes-related nerve damage, for instance, sustain poorly healing foot ulcers as a result of decreased sensation.[29] A much smaller number of people are insensitive to pain due to an inborn abnormality of the nervous system, known as "congenital insensitivity to pain".[27] Children with this condition incur carelessly repeated damage to their tongue, eyes, joints, skin, and muscles. They may attain adulthood, but have a reduced life expectancy. Most people with congenital insensitivity to pain have one of five hereditary sensory and autonomic neuropathies (which includes familial dysautonomia and congenital insensitivity to pain with anhidrosis).[30] These conditions feature decreased sensitivity to pain together with other neurological abnormalties, particularly of the autonomic nervous system.[27][30] A very rare syndrome with isolated congenital insensitivity to pain has been linked with mutations in the SCN9A gene, which codes for a sodium channel (Nav1.7) necessary in conducting pain nerve stimuli.[31][32]

[edit] Effect on functioning

Experimental subjects challenged by acute pain and patients in chronic pain experience impairments in attention control, working memory, mental flexibility, problem solving, and information processing speed.[33] Acute and chronic pain are also associated with increased depression, anxiety, fear, and anger.[34] "If I have matters right, the consequences of pain will include direct physical distress, unemployment, financial difficulties, marital disharmony, and difficulties in concentration and attention" Harold Merskey 2000[35]

[edit] Theory
[edit] Specificity

Descartes' pain pathway. In his 1664 Treatise of Man, Ren Descartes traced a pain pathway. "Particles of heat" (A) activate a spot of skin (B) attached by a fine thread (cc) to a valve in the brain (de) where this activity opens the valve, allowing the animal spirits to flow from a cavity (F) into the muscles that then flinch from the stimulus, turn the head and eyes toward the affected body part, and move the hand and turn the body protectively. The underlying premise of this model - that pain is the direct product of a noxious stimulus activating a dedicated pain pathway, from a receptor in the skin, along a thread or chain of nerve fibers to the pain center in the brain, to a mechanical behavioral response - remained the dominant perspective on pain until the mid-nineteen sixties.[36]

[edit] Pattern
This "specificity theory" (specific pain receptor and pathway) was challenged by the theory, proposed initially in 1874 by Wilhelm Erb, that a pain signal can be generated by stimulation of any sensory receptor, provided the stimulation is intense enough: the pattern of stimulation (intensity over time and area), not the receptor type, determines whether nociception occurs. Alfred Goldscheider (1894) proposed that over time, activity from many sensory fibers might accumulate in the dorsal horns of the spinal cord and begin to signal pain once a certain threshold of accumulated stimulation has been crossed. In 1953, Willem Noordenbos observed that a signal carried from the area of injury along large diameter "touch, pressure or vibration" fibers may inhibit the signal carried by the thinner "pain" fibers - the ratio of large fiber signal to thin fiber signal determining pain intensity; hence, we rub a smack. This was taken as a demonstration that pattern of stimulation (of large and thin fibers in this instance) modulates pain intensity.[37]

[edit] Gate control

Ronald Melzack and Patrick Wall introduced their "gate control" theory of pain in the 1965 Science article "Pain Mechanisms: A New Theory".[38] The authors proposed that thin (pain) and large diameter (touch, pressure, vibration) nerve fibers carry information from the site of injury to two destinations in the dorsal horn of the spinal

cord: the "inhibitory" cells and the "transmission" cells. Signals from both thin and large diameter fibers excite the transmission cells, and when the output of the transmission cells exceeds a critical level, pain begins. The job of the inhibitory cells is to inhibit activation of the transmission cells. The transmission cells are the gate on pain, and inhibitory cells can shut the gate. When thin (pain) and large (touch, etc.) fibers, activated by a noxious event, excite a spinal cord transmission cell, they also act on its inhibitory cells. The thin fibers impede the inhibitory cells (tending to leave the gate open) while the large diameter fibers excite the inhibitory cells (tending to close the gate). So, the more large fiber activity relative to thin fiber activity coming from the inhibitory cell's receptive field, the less pain is felt. The authors had conceived a neural "circuit diagram" to explain why we rub a smack.[36] They pictured not only a signal traveling from the site of injury to the inhibitory and transmission cells and up the spinal cord to the brain, but also a signal traveling from the site of injury directly up the cord to the brain (bypassing the inhibitory and transmission cells) where, depending on the state of the brain, it may trigger a signal back down the spinal cord to modulate inhibitory cell activity (and so pain intensity). This was the first theory to offer a physiological explanation for the previously reported effect of psychology on pain perception.[39]

[edit] Dimensions
In 1968 Ronald Melzack and Kenneth Casey described pain in terms of its three dimensions: "Sensory-discriminative" (sense of the intensity, location, quality and duration of the pain), "Affective-motivational" (unpleasantness and urge to escape the unpleasantness), and "Cognitive-evaluative" (cognitions such as appraisal, cultural values, distraction and hypnotic suggestion).[40] They theorized that pain intensity (the sensory discriminative dimension) and unpleasantness (the affectivemotivational dimension) are not simply determined by the magnitude of the painful stimulus, but higher cognitive activities (the cognitive-evaluative dimension) can influence perceived intensity and unpleasantness. Cognitive activities "may affect both sensory and affective experience or they may modify primarily the affectivemotivational dimension. Thus, excitement in games or war appears to block both dimensions of pain, while suggestion and placebos may modulate the affectivemotivational dimension and leave the sensory-discriminative dimension relatively undisturbed." (p. 432) The paper ends with a call to action: "Pain can be treated not only by trying to cut down the sensory input by anesthetic block, surgical intervention and the like, but also by influencing the motivational-affective and cognitive factors as well." (p. 435)

[edit] Theory today

Regions of the cerebral cortex associated with pain. Wilhelm Erb's (1874) early pattern theory hypothesis, that a pain signal can be generated by intense enough stimulation of any sensory receptor, has been soundly disproved.[41] The thin (A-delta and C) peripheral sensory fibers carry information regarding the state of the body to the spinal cord.[42] Some of these thin fibers do not differentiate noxious from non-noxious stimuli, while others, nociceptors, respond only to painfully intense stimuli.[41] Because the A-delta fiber is thinly sheathed in an electrically insulating material (myelin), it carries its signal faster (1030 m/s) than the unmyelinated C fiber (2.5 m/s).[43] Pain evoked by the (faster) A-delta fibers is described as sharp and is felt first. This is followed by a duller pain, often described as burning, carried by the C fibers.[44] Spinal cord fibers dedicated to carrying A-delta fiber pain signals, and others dedicated to carrying C fiber pain signals up the spinal cord to the thalamus in the brain have been identified.[45] Pain-related activity in the thalamus spreads to the insular cortex (thought to embody, among other things, the feeling that distinguishes pain from other homeostatic emotions such as itch and nausea) and anterior cingulate cortex (thought to embody, among other things, the motivational element of pain);[42] and pain that is distinctly located also activates the primary and secondary somatosensory cortices.[46] Melzack and Casey's 1968 picture of the dimensions of pain is as influential today as ever, firmly framing theory and guiding research in the functional neuroanatomy and psychology of pain. A. D. (Bud) Craig and Derek Denton include pain in a class of feelings they name, respectively, "homeostatic" or "primordial" emotions. These are feelings such as hunger, thirst and fatigue, evoked by internal body states, communicated to the central nervous system by interoceptors, which motivate behavior aimed at maintaining the internal milieu at its ideal state. Craig and Denton distinguish these feelings from the "classical emotions" such as love, fear and anger, which are elicited by environmental stimuli sensed through the nose, eyes and ears.[47][48]

[edit] Evolutionary and behavioral role

Pain is part of the body's defense system, producing a reflexive retraction from the painful stimulus, and tendencies to protect the affected body part while it heals, and avoid that harmful situation in the future.[3][49] It is an important part of animal life, vital to healthy survival. People with congenital insensitivity to pain have reduced life expectancy.[27] In his book, The Greatest Show on Earth, biologist Richard Dawkins grapples with the question of why pain has to be so very painful. He describes the alternative as a simple, mental raising of a "red flag". To argue why that red flag might be insufficient, Dawkins explains that drives must compete with each other within living beings. The most fit creature would be the one whose pains are well balanced. Those pains which mean certain death when ignored will become the most powerfully felt. The relative intensities of pain, then, may resemble the relative importance of that risk to our ancestors (lack of food, too much cold, or serious injuries are felt as agony, whereas minor damage is felt as mere discomfort). This resemblance will not be perfect, however, because natural selection can be a poor designer. The result is often glitches in animals, including supernormal stimuli. Such glitches help explain pains which are not, or at least no longer directly adaptive (e.g. perhaps some forms of toothache, or injury to fingernails).[50] Idiopathic pain (pain that persists after the trauma or pathology has healed, or that arises without any apparent cause), may be an exception to the idea that pain is helpful to survival, although some psychodynamic psychologists argue that such pain is psychogenic, enlisted as a protective distraction to keep dangerous emotions unconscious.[51]

[edit] Thresholds
In pain science, thresholds are measured by gradually increasing the intensity of a stimulus such as electric current or heat applied to the body. The pain perception threshold is the point at which the stimulus begins to hurt, and the pain tolerance threshold is reached when the subject acts to stop the pain. Differences in pain perception and tolerance thresholds are associated with, among other factors, ethnicity, genetics, and sex. People of Mediterranean origin report as painful some radiant heat intensities that northern Europeans describe as nonpainful, and Italian women tolerate less intense electric shock than Jewish or Native American women. Some individuals in all cultures have significantly higher than normal pain perception and tolerance thresholds. For instance, patients who experience painless heart attacks have higher pain thresholds for electric shock, muscle cramp and heat.[52] Women have lower pain perception and tolerance thresholds than men, and this sex difference appears to apply to all ages, including newborn infants.[53]

[edit] Assessment

See also: Pain scales and Pain ladder

A person's self report is the most reliable measure of pain, with health care professionals tending to underestimate severity.[54] A definition of pain widely employed in nursing, emphasizing its subjective nature and the importance of believing patient reports, was introduced by Margo McCaffery in 1968: "Pain is whatever the experiencing person says it is, existing whenever he says it does".[55] To assess intensity, the patient may be asked to locate their pain on a scale of 0 to 10, with 0 being no pain at all, and 10 the worst pain they have ever felt. Quality can be established by having the patient complete the McGill Pain Questionnaire indicating which words best describe their pain.[6]

[edit] Multidimensional pain inventory

The Multidimensional Pain Inventory (MPI) is a questionnaire designed to assess the psychosocial state of a person with chronic pain. Analysis of MPI results by Turk and Rudy (1988) found three classes of chronic pain patient: "(a) dysfunctional, people who perceived the severity of their pain to be high, reported that pain interfered with much of their lives, reported a higher degree of psychological distress caused by pain, and reported low levels of activity; (b) interpersonally distressed, people with a common perception that significant others were not very supportive of their pain problems; and (c) adaptive copers, patients who reported high levels of social support, relatively low levels of pain and perceived interference, and relatively high levels of activity."[56] Combining the MPI characterization of the person with their IASP five-category pain profile is recommended for deriving the most useful case description.[10]

[edit] In nonverbal patients

See also: Pain and dementia and Pain in babies
When a person is non-verbal and cannot self report pain, observation becomes critical, and specific behaviors can be monitored as pain indicators. Behaviors such as facial grimacing and guarding indicate pain, as well as an increase or decrease in vocalizations, changes in routine behavior patterns and mental status changes. Patients experiencing pain may exhibit withdrawn social behavior and possibly experience a decreased appetite and decreased nutritional intake. A change in condition that deviates from baseline such as moaning with movement or when manipulating a body part, and limited range of motion are also potential pain indicators. In patients who possess language but are incapable of expressing themselves effectively, such as those with dementia, an increase in confusion or display of aggressive behaviors or agitation, may signal that discomfort exists, and further assessment is necessary. Infants feel pain but they lack the language needed to report it, so communicate distress by crying. A non-verbal pain assessment should be conducted involving the parents, who will notice changes in the infant not obvious to the health care

provider. Pre-term babies are more sensitive to painful stimuli than full term babies.[57]

[edit] Other barriers to reporting

An aging adult may not respond to pain in the way that a younger person would. Their ability to recognize pain may be blunted by illness or the use of multiple prescription drugs. Depression may also keep the older adult from reporting they are in pain. The older adult may also quit doing activities they love because it hurts too much. Decline in self-care activities (dressing, grooming, walking, etc.) may also be indicators that the older adult is experiencing pain. The older adult may refrain from reporting pain because they are afraid they will have to have surgery or will be put on a drug they become addicted to. They may not want others to see them as weak, or may feel there is something impolite or shameful in complaining about pain, or they may feel the pain is deserved punishment for past transgressions.[58] Cultural barriers can also keep a person from telling someone they are in pain. Religious beliefs may prevent the individual from seeking help. They may feel certain pain treatment is against their religion. They may not report pain because they feel it is a sign that death is near. Many people fear the stigma of addiction and avoid pain treatment so as not to be prescribed addicting drugs. Many Asians do not want to lose respect in society by admitting they are in pain and need help, believing the pain should be borne in silence, while other cultures feel they should report pain right away and get immediate relief.[57] Gender can also be a factor in reporting pain. Gender differences are usually the result of social and cultural expectations, with women expected to be emotional and show pain and men stoic, keeping pain to themselves.[57]

[edit] As an aid to diagnosis

Pain is a symptom of many medical conditions. Knowing the time of onset, location, intensity, pattern of occurrence (continuous, intermittent, etc.), exacerbating and relieving factors, and quality (burning, sharp, etc.) of the pain will help the examining physician to accurately diagnose the problem. For example, chest pain described as extreme heaviness may indicate myocardial infarction, while chest pain described as tearing may indicate aortic dissection.[59][60]

[edit] Management
Main article: Pain management
Inadequate treatment of pain is widespread throughout surgical wards, intensive care units, accident and emergency departments, in general practice, in the management of all forms of chronic pain including cancer pain, and in end of life care.[61] This neglect is extended to all ages, from neonates to the frail elderly.[62] African and Hispanic Americans are more likely than others to suffer needlessly in

the hands of a physician;[63] and women's pain is more likely to be undertreated than men's.[64] The International Association for the Study of Pain advocates that the relief of pain should be recognized as a human right, that chronic pain should be considered a disease in its own right, and that pain medicine should have the full status of a specialty.[65] It is a specialty only in China and Australia at this time.[66] Elsewhere, pain medicine is a subspecialty under disciplines such as anesthesiology, physiatry, neurology, palliative medicine and psychiatry.[67]

[edit] Medication
Acute pain is usually managed with medications such as analgesics and anesthetics. Management of chronic pain, however, is much more difficult and may require the coordinated efforts of a pain management team, which typically includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists, and nurse practitioners.[68] Sugar taken orally reduces the total crying time but not the duration of the first cry in newborns undergoing a painful procedure (a single lancing of the heel). It does not moderate the effect of pain on heart rate[69] and a recent single study found that sugar did not significantly affect pain-related electrical activity in the brains of newborns one second after the heel lance procedure.[70][71] Sweet oral liquid moderately reduces the incidence and duration of crying caused by immunization injection in children between one and twelve months of age.[72]

[edit] Psychological
Individuals with more social support experience less cancer pain, take less pain medication, report less labor pain and are less likely to use epidural anesthesia during childbirth or suffer from chest pain after coronary artery bypass surgery.[73] Suggestion can significantly affect pain intensity. About 35% of people report marked relief after receiving a saline injection they believe to have been morphine. This "placebo" effect is more pronounced in people who are prone to anxiety, so anxiety reduction may account for some of the effect, but it does not account for all of the effect. Placebos are more effective in intense pain than mild pain; and they produce progressively weaker effects with repeated administration.[74] It is possible for many chronic pain sufferers to become so absorbed in an activity or entertainment that the pain is no longer felt, or is greatly diminished.[75] Cognitive behavioral therapy (CBT) is effective in reducing the suffering associated with chronic pain in some patients but the reduction in suffering is quite modest, and the CBT method employed seems to have no effect on outcome.[76]

[edit] Alternative medicine

Pain is the most common reason for people to use complementary and alternative medicine.[77] An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the British Medical Journal, concluded there is little difference in the effect of real, sham and no acupuncture.[78] There is interest in the relationship between vitamin D and pain, but the evidence so far from controlled trials for such a relationship, other than in osteomalacia, is unconvincing.[79] A 2007 review of 13 studies found evidence for the efficacy of hypnosis in the reduction of pain in some conditions, though the number of patients enrolled in the studies was low, bringing up issues of power to detect group differences, and most lacked credible controls for placebo and/or expectation. The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions."[80] A 2003 meta-analysis of randomized clinical trials found that spinal manipulation was "more effective than sham therapy but was no more or less effective than general practitioner care, analgesics, physical therapy, exercise, or back school" in the treatment of low back pain.[81]

[edit] Epidemiology
Pain is the main reason for visiting the emergency department in more than 50% of cases[82] and is present in 30% of family practice visits.[83] Several epidemiological studies from different countries have reported widely varying prevalence rates for chronic pain, ranging from 12-80% of the population.[84] It becomes more common as people approach death. A study of 4,703 patients found that 26% had pain in the last two years of life, increasing to 46% in the last month.[85] A survey of 6,636 children (018 years of age) found that, of the 5,424 respondents, 54% had experienced pain in the preceding three months. A quarter reported having experienced recurrent or continuous pain for three months or more, and a third of these reported frequent and intense pain. The intensity of chronic pain was higher for girls, and girls' reports of chronic pain increased markedly between ages12 and 14.[86]

[edit] Society and culture

The okipa ceremony as witnessed by George Catlin, circa 1835. The nature or meaning of physical pain has been diversely understood by religious or secular traditions from antiquity to modern times.[87][88] Physical pain is an important political topic in relation to various issues, including pain management policy, drug control, animal rights or animal welfare, torture, pain compliance. In various contexts, the deliberate infliction of pain in the form of corporal punishment is used as retribution for an offence, or for the purpose of disciplining or reforming a wrongdoer, or to deter attitudes or behaviour deemed unacceptable. In some cultures, extreme practices such as mortification of the flesh or painful rites of passage are highly regarded. Philosophy of pain is a branch of philosophy of mind that deals essentially with physical pain. Identity theorists assert that the mental state of pain is completely identical with some physiological state. Functionalists consider that pain as a mental state is constituted solely by its functional role, by its causal relations to other mental states, sensory inputs, and behavioral outputs. More generally, it is often as a part of pain in the broad sense, i.e. suffering, that physical pain is dealt with in culture, religion, philosophy, or society.

Sleep disorder
From Wikipedia, the free encyclopedia

(Redirected from Sleep disorders) Jump to: navigation, search It has been suggested that Sleeping disorders in truck drivers be merged into this article or section. (Discuss) Proposed since April 2011.

Sleep disorder
Classification and external resources
ICD-10 ICD-9 DiseasesDB eMedicine F51., G47. 307.4, 327, 780.5 26877 med/609

MeSH

D012893

A sleep disorder (somnipathy) is a medical disorder of the sleep patterns of a person or animal. Some sleep disorders are serious enough to interfere with normal physical, mental and emotional functioning. A test commonly ordered for some sleep disorders is the polysomnography. Disruptions in sleep can be caused by a variety of issues, from teeth grinding (bruxism) to night terrors. When a person suffers from difficulty in sleeping with no obvious cause, it is referred to as insomnia.[1] In addition, sleep disorders may also cause sufferers to sleep excessively, a condition known as hypersomnia. Management of sleep disturbances that are secondary to mental, medical, or substance abuse disorders should focus on the underlying conditions.

Contents
[hide]

1 2 3 4 5 6 7

Common disorders Types General principles of treatment Sleep medicine See also External links References

[edit] Common disorders

The most common sleep disorders include:

Primary insomnia: Chronic difficulty in falling asleep and/or maintaining sleep when no other cause is found for these symptoms. Bruxism: Involuntarily grinding or clenching of the teeth while sleeping. Delayed sleep phase syndrome (DSPS): inability to awaken and fall asleep at socially acceptable times but no problem with sleep maintenance, a disorder of circadian rhythms. (Other such disorders are advanced sleep phase syndrome (ASPS), non-24-hour sleep-wake syndrome (Non-24), and irregular sleep wake rhythm, all much less common than DSPS, as well as the transient jet lag and shift work sleep disorder.) Hypopnea syndrome: Abnormally shallow breathing or slow respiratory rate while sleeping. Narcolepsy: Excessive daytime sleepiness (EDS) often culminating in falling asleep spontaneously but unwillingly at inappropriate times.

Cataplexy: a sudden weakness in the motor muscles that can result in collapse to the floor. Night terror: Pavor nocturnus, sleep terror disorder: abrupt awakening from sleep with behavior consistent with terror. Parasomnias: Disruptive sleep-related events involving inappropriate actions during sleep; sleep walking and night-terrors are examples. Periodic limb movement disorder (PLMD): Sudden involuntary movement of arms and/or legs during sleep, for example kicking the legs. Also known as nocturnal myoclonus. See also Hypnic jerk, which is not a disorder. Rapid eye movement behavior disorder (RBD): Acting out violent or dramatic dreams while in REM sleep (REM sleep disorder or RSD) Restless legs syndrome (RLS): An irresistible urge to move legs. RLS sufferers often also have PLMD. Situational circadian rhythm sleep disorders: shift work sleep disorder (SWSD) and jet lag. Sleep Apnea, and mostly Obstructive sleep apnea: Obstruction of the airway during sleep, causing lack of sufficient deep sleep; often accompanied by snoring. Other forms of sleep apnea are less common. Sleep paralysis: is characterized by temporary paralysis of the body shortly before or after sleep. Sleep paralysis may be accompanied by visual, auditory or tactile hallucinations. Not a disorder unless severe. Often seen as part of narcolepsy. Sleepwalking or somnambulism: Engaging in activities that are normally associated with wakefulness (such as eating or dressing), which may include walking, without the conscious knowledge of the subject. Nocturia: A frequent need to get up and go to the bathroom to urinate at night. It differs from Enuresis, or bed-wetting, in which the person does not arouse from sleep, but the bladder nevertheless empties.[2] Somniphobia: a dread of sleep.

[edit] Types

Dyssomnias - A broad category of sleep disorders characterized by either hypersomnolence or insomnia. The three major subcategories include intrinsic (i.e., arising from within the body), extrinsic (secondary to environmental conditions or various pathologic conditions), and disturbances of circadian rhythm. MeSH o Insomnia o Narcolepsy o Sleep Disordered Breathing (SDB), including (non exhaustive): Several types of Sleep apnea Snoring Upper airway resistance syndrome o Restless leg syndrome o Periodic limb movement disorder o Hypersomnia Recurrent hypersomnia - including Kleine-Levin syndrome

Posttraumatic hypersomnia "Healthy" hypersomnia o Circadian rhythm sleep disorders Delayed sleep phase syndrome Advanced sleep phase syndrome Non-24-hour sleep-wake syndrome Parasomnias - A category of sleep disorders that involve abnormal and unnatural movements, behaviors, emotions, perceptions, and dreams in connection with sleep. o REM sleep behaviour disorder o Sleep terror o Sleepwalking (or somnambulism) o Bruxism (Tooth-grinding) o Bedwetting or sleep enuresis. o Sleep talking (or somniloquy) o Sleep sex (or sexsomnia) o Exploding head syndrome - Waking up in the night hearing loud noises. Medical or Psychiatric Conditions that may produce sleep disorders o Psychosis (such as Schizophrenia) o Mood disorders Depression Anxiety o Panic o Alcoholism Sleeping sickness - a parasitic disease which can be transmitted by the Tsetse fly.

[edit] General principles of treatment

Treatments for sleep disorders generally can be grouped into four categories:

behavioral/ psychotherapeutic treatments rehabilitation/management medications other somatic treatments

None of these general approaches is sufficient for all patients with sleep disorders. Rather, the choice of a specific treatment depends on the patient's diagnosis, medical and psychiatric history, and preferences, as well as the expertise of the treating clinician. Often, behavioral/psychotherapeutic and pharmacological approaches are not incompatible and can effectively be combined to maximize therapeutic benefits. Management of sleep disturbances that are secondary to mental, medical, or substance abuse disorders should focus on the underlying conditions. Medications and somatic treatments may provide the most rapid symptomatic relief from some sleep disturbances. Some disorders, such as narcolepsy, are best treated

pharmacologically. Others, such as chronic and primary insomnia, may be more amenable to behavioral interventions, with more durable results. Chronic sleep disorders in childhood, which affect some 70% of children with developmental or psychological disorders, are under-reported and under-treated. Sleep-phase disruption is also common among adolescents, whose school schedules are often incompatible with their natural circadian rhythm. Effective treatment begins with careful diagnosis using sleep diaries and perhaps sleep studies. Modifications in sleep hygiene may resolve the problem, but medical treatment is often warranted.[3] Special equipment may be required for treatment of several disorders such as obstructive apnea, the circadian rhythm disorders and bruxism. In these cases, when severe, an acceptance of living with the disorder, however well managed, is often necessary. Some sleep disorders have been found to compromise glucose metabolism.[4]

[edit] Sleep medicine

Main article: Sleep medicine
Due to rapidly increasing knowledge about sleep in the 20th century, including the discovery of REM sleep and sleep apnea, the medical importance of sleep was recognized. The medical community began paying more attention than previously to primary sleep disorders, such as sleep apnea, as well as the role and quality of sleep in other conditions. By the 1970s in the USA, clinics and laboratories devoted to the study of sleep and sleep disorders had been founded, and a need for standards arose.

Pediatric Polysomnography. Sleep Medicine is now a recognized subspecialty within internal medicine, family medicine, pediatrics, otolaryngology, psychiatry and neurology in the United States. Certification in Sleep Medicine shows that the specialist: "has demonstrated expertise in the diagnosis and management of clinical conditions that occur during sleep, that disturb sleep, or that are affected by disturbances in the wake-sleep cycle. This specialist is skilled in the analysis and interpretation of

comprehensive polysomnography, and well-versed in emerging research and management of a sleep laboratory."[5] Competence in sleep medicine requires an understanding of a myriad of very diverse disorders, many of which present with similar symptoms such as excessive daytime sleepiness, which, in the absence of volitional sleep deprivation, "is almost inevitably caused by an identifiable and treatable sleep disorder", such as sleep apnea, narcolepsy, idiopathic central nervous system (CNS) hypersomnia, Kleine-Levin syndrome, menstrual-related hypersomnia, idiopathic recurrent stupor, or circadian rhythm disturbances.[6] Another common complaint is insomnia, a set of symptoms which can have a great many different causes, physical and mental. Management in the varying situations differs greatly and cannot be undertaken without a correct diagnosis. Sleep dentistry (bruxism, snoring and sleep apnea), while not recognized as one of the nine dental specialties, qualifies for board-certification by the American Board of Dental Sleep Medicine (ABDSM). The resulting Diplomate status is recognized by the American Academy of Sleep Medicine (AASM), and these dentists are organized in the Academy of Dental Sleep Medicine (USA).[7] The qualified dentists collaborate with sleep physicians at accredited sleep centers and can provide oral appliance therapy and upper airway surgery to treat or manage sleep-related breathing disorders.[8] In the UK, knowledge of sleep medicine and possibilities for diagnosis and treatment seem to lag. Guardian.co.uk quotes the director of the Imperial College Healthcare Sleep Centre: "One problem is that there has been relatively little training in sleep medicine in this country certainly there is no structured training for sleep physicians."[9] The Imperial College Healthcare site[10] shows attention to obstructive sleep apnea syndrome (OSA) and very few other sleep disorders.